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of 2016. ii Moran’s I, a metric of spatial clustering, was 0.58 (p < 0.001) for poverty and was 0.61 (p < 0.001) for Economic Opportunity and Indicators of Opioid Prevalence Vary Markedly across Geographic Regions Indicators of economic opportunity and the opioid epidemic were not homogeneous across the country. Figure 4 shows the quintiles of poverty and unemployment rates for 2016. Poverty and unemployment rates were clearly geographically concentrated in certain parts of the country. Statistical measures show that both of these measures had a high degree of spatial clustering (see Appendix for more details). ii Poverty rates were much lower in the Midwestern states than in other areas. In fact, the average poverty rate for a Midwestern county was 13.2 percent in 2016, versus 17.3 percent for all other areas combined. Additionally, poverty and unemployment rates were particularly pronounced and clustered in Appalachia, the South, and the West. Moreover, the poverty rates were high in some areas: while the average poverty rate was 15.8 percent in 2016, over 250 counties in the U.S. had a poverty rate greater than 25 percent. Similarly, all four measures of the opioid epidemic show spatial clustering as well, consistent with other research. 12 The bottom two maps in Figure 4 show quintiles of per capita retail opioid sales and overdose death rates across the country. Though not shown, per capita Medicare opioid prescriptions and opioid related hospitalizations had similar geographic patterns. Economic Indicators Were Strongly Related to Rates of Prescription Opioid Sales and Drug Overdose Deaths in Certain Geographic Areas Figures 5 and 6 show the geographic relationships between poverty rates and per capita retail opioid sales, and between poverty rates and drug overdose deaths, respectively; they reveal a strong relationship unemployment. Moran’s I is measured on a scale from −1 to 1, where positive values mean that counties near one another tend to have similar values. 6 between these variables. Counties with higher per capita opioid sales are colored in red, and areas of higher poverty rates are displayed in blue. These colors combine in areas that have high rates of poverty and high rates of opioid sales. In 2016, counties with higher poverty and higher per capita retail opioid sales, as well as higher overdose death rates, were concentrated in several geographic areas. These areas include parts of the west coast; including northern California and southwestern Oregon; Appalachia; and portions of the Midwest and South, including Missouri, Arkansas, Oklahoma, Louisiana, and Alabama. In other parts of the country the relationship is more scattered, particularly across the two drug measures. New England, for example, had relatively high rates of opioid sales and overdose deaths without a consistently higher poverty rate. Appendix Figures B1 and B2 present the same results for unemployment rates. The relationships are similar, with counties clustered in the same identified regions having high rates of unemployment as well as high drug overdose death rates and prescription opioid sales. Figure 4. County Poverty Rates, Unemployment Rates, Per Capita Retail Opioid Sales, and Drug Overdose Death Rates, 2016 Per Capita Retail Opioid Sales Drug Overdose Death Rates Poverty Rates Unemployment Rates Sources: Poverty Rates: U.S. Census Bureau Small Area Income and Poverty Estimates. Unemployment Rates: Bureau of Labor Statistics. Opioid Sales: DEA Automation of Reports and Consolidated Orders System. Overdose Deaths: CDC Small Area Estimates of Drug Mortality. 7 Figure 5. Poverty Rates and Per Capita Retail Opioid Sales, 2016 Sources: U.S. Census Bureau Small Area Income and Poverty Estimates, DEA Automation of Reports and Consolidated Orders System. Note: Each variable is split into tertiles. Figure 6. Poverty Rates and Drug Overdose Death Rates, 2016 Sources: U.S. Census Bureau Small Area Income and Poverty Estimates, CDC Small Area Estimates of Drug Mortality. Note: Each variable is split into tertiles. 8 Some Counties with Less Economic Opportunity Are Insulated from the Substance Use and Opioid Epidemic Figures 5 and 6 display areas of the country where the